adrenaline

EACCI guideline recommendations for the use of Adrenaline in the treatment of anaphylaxis.

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Anaphylaxis is a medical emergency that is defined by the sudden onset of symptoms involving several organ systems. Adrenaline has been used as a first-line treatment for anaphylaxis without evidence of serious adverse effects. According to the European Academy of Allergy and Clinical Immunology (EACCI) guideline, recommendations for the use of Adrenaline in the treatment of anaphylaxis are as follows:

1. Intramuscular Adrenaline is the first-line treatment of anaphylaxis, which should be administered immediately in the mid-thigh area. 

However, in cases of refractory respiratory distress or hypotension, intramuscular Adrenaline may not be effective; therefore, intravenous Adrenaline should be used.

2. In the community, Adrenaline autoinjectors are recommended as the first-line of treatment for anaphylaxis.

3. Pharmacokinetic data should be provided for each Adrenaline autoinjector because the Adrenaline autoinjector product are not interchangeable.

 i. Absolute indications for Adrenaline autoinjectors:

  • A history of food, latex, or aeroallergen-induced anaphylaxis.
  • Prior exercise-induced anaphylaxis.
  • Prior idiopathic anaphylaxis.
  • Co-existing unstable or moderate to severe, persistent asthma and a food allergy.
  • Hymenoptera venom allergy in untreated patients with more than cutaneous/mucosal systemic reactions or high risk of re-exposure.
  • During and after hymenoptera venom immunotherapy (VIT), in patients with more than cutaneous/mucosal systemic reactions, if risk factors for recurrence are present.
  • In adults with a history of a systemic reaction associated with underlying systemic mastocytosis. Children with blisters, severe skin involvement (>50% body surface) and elevated basal serum tryptase levels (>20 ng/ml) in the first 3 years of life.

 ii. Adrenaline autoinjectors should be prescribed with any of the following additional factors (if more than one is present):

  • Prior mild-to-moderate food allergy associated with anaphylaxis in the patient’s region (e.g., peanut and/or tree nut, cow’s milk, seafood depending on triggers for anaphylactic reactions in that area).
  • Teenagers or young adults with a food allergy with a history of mild-to-moderate reactions.
  • In the case of away from medical support or prolonged foreign trip and a past mild-to-moderate allergic reaction to a food, hymenoptera venom, latex, or aeroallergens.
  • Prior mild-to-moderate allergic reaction to food traces.
  • Hymenoptera venom or drug allergy in patients with more than cardiovascular disease and cutaneous/mucosal systemic reactions.
  • Oral immunotherapy for food allergy.

  a) The recommended dose of intramuscular Adrenaline autoinjectors:

  • For children from 7.5 kg to 25-30 kg: 0.15 mg.
  • For children from 25-30 kg: 0.3 mg. 
  • For adolescents and adults who are at risk of anaphylaxis: At least 0.3 mg. 
  • A patient who is overweight or has a history of life-threatening anaphylaxis: may benefit from the dose of 0.5 mg. 

An autoinjector can be substituted with a prefilled syringe and a dose of 0.01 mg/kg of Adrenaline when an infant weighs ˂7.5 kg who is at risk of anaphylaxis. When a patient presents severe anaphylaxis in a clinical setting, a higher dose (such as 0.5 mg or 0.3 mg repeated for an older adolescent or adult) might be considered.

Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis

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Abstract

Background International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β2-agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β2-agonist in acute asthma.

Methods We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β2-agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death.

Results Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I2=56%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β2-agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β2-agonist improved outcomes.

Conclusion The low-quality evidence available suggests that epinephrine and selective β2-agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β2-agonist improves outcome.